Myringoplasty and tympanoplasty - Vula

OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD &
NECK OPERATIVE SURGERY
MYRINGOPLASTY & TYMPANOPLASTY
The goals myringoplasty and tympanoplasty are to achieve a dry, self-cleansing
ear while preserving or restoring hearing.
Myringoplasty refers to grafting of the
tympanic membrane without inspection of
the ossicular chain.
Tympanoplasty entails grafting of the
tympanic membrane with inspection of
ossicular chain with/without reconstruction
of the middle ear hearing mechanism.
Ossiculoplasty is reconstruction of the
hearing mechanism using either an
autologous graft or prosthesis.
Meatoplasty involves enlargement of the
lateral cartilaginous portion of the external
auditory canal. A narrow entrance to the
ear canal within the cartilaginous portion
of the canal prevents proper ventilation and
self-cleaning of the ear canal, and may
compromise
hearing
aid
fitting.
(Meatoplasty video)
Canalplasty is partial or total widening of
the bony portion of the external ear canal.
In order to visualise the tympanic annulus,
particularly in anterior or subtotal
perforations, canalplasty is essential and
may be an integral part of myringoplasty
or tympanoplasty. (Canalplasty video)
Preoperative assessment
Otomicroscopy: Both the size and site of
the perforation determine the surgical
approach
Size of perforation: Is the perforation
limited or subtotal? Microperforations
may have a higher failure rate than
larger perforations
Site of perforation: Does the
perforation extend far into the
Tashneem Harris & Thomas Linder
anterosuperior quadrant? Does it only
involve the posterior quadrant?
What is the status of the middle ear
mucosa?
Is
it
normal
or
granular/polypoidal? Is there airflow
through the perforation with a Valsalva
manoeuvre?
Is the handle of the malleus
medialised? This may necessitate an
ossiculoplasty even in the presence of
an intact ossicular chain
Is an ossiculoplasty required?
Does the ossiculoplasty need to be
staged?
What is the status of the contralateral
ear?
Audiometry: This should have been done
recently i.e. within the preceding 3months.
Correlate the size of the perforation with
the audiogram, particularly the air-bone
gap. Lerut, Pfammater & Linder
investigated the correlation between airbone gap and perforation size. There was a
strong correlation between air-bone gap
and increasing perforation size; however
the location (anterior/posterior) had no
impact on hearing. The greatest changes in
air-bone gap were at 0.5 and 4kHz, and the
smallest changes at 2kHz. The audiograms
thus revealed a consistent “V”-shaped
pattern with the turning point at
2 kHz. This can be explained by the fact
that 2 kHz is the resonance frequency of
the middle ear; thus hearing is better
preserved at this frequency. The clinical
significance is that one can predict the
expected air-bone gap by looking at the
size of the perforation. If the audiogram
does not correspond with the expected
findings, then additional middle ear
pathology must be expected. If the airbone gap is greater than 30dB, then an
ossiculoplasty may be required.
Tympanometry: Tympanometry provides
additional information regarding the
patient’s middle ear function; it can also be
used to assess eustachian tube dysfunction
(see below). The curve is always flat in the
presence of a tympanic membrane
perforation, but the volume measurements
are of interest.
Surgical Approaches
Eustachian tube function: Successful
myringoplasty depends on ventilation of
the middle ear and mastoid which in turn
affects the final position of the
reconstructed tympanic membrane.
CT scan: The best assessment of
eustachian tube function is a CT scan
of the mastoid; favourable findings are
a well-aerated middle ear and a wellpneumatised mastoid
Tympanometric volume: This is a
good indicator of eustachian tube
function and ventilation of the middle
ear in the presence of a tympanic
membrane perforation when CT
scanning is not available. As a general
rule, values for ear canal volume in the
presence of an intact tympanic
membrane should be approximately 1,5
- 2.0ml (adults). With a perforation of
the tympanic membrane, the ear canal
volume measurement should be high,
because the instrument will measure
the volume of the entire middle ear
space and mastoid in addition to the
volume of the ear canal (4-5mls in
adults). If the volume is less than this
(e.g. 2,5-3ml) then ventilation of the
middle ear cleft and mastoid must be
poor.
Valsalva manoeuvre: Absence of a
positive Valsalva test i.e. absence of
airflow through the perforation on
performing a Valsalva manoeuvre,
identifies patients at risk of poorer
outcome
Transcanal approach: The ear operation
is performed through an ear speculum
placed in the external ear canal. Because
exposure is one of the limiting factors of
the transcanal approach, its use is limited
to repairing traumatic perforations or in
cases where there is a wide ear canal with
a posterior perforation. The ear canal has
to be wide enough, and one should be able
to visualise the entire margins of the
perforation; most often this would apply to
posterior perforations. The anterior margin
of an anterior perforation may be obscured
by an overhanging canal wall.
Optimal graft take depends on securing the
graft; this in turn depends on having
sufficient surgical exposure in order to
stabilise the graft. Three different
approaches may be used i.e. transcanal,
endaural or retroauricular.
Endaural and retroauricular approaches:
These afford better exposure. These two
approaches will next be discussed in more
detail.
Endaural Approach
The endaural approach entails making an
incision between the tragus and helix; the
entrance to the ear canal is then stretched
open with endaural retractors. It is a good
approach to use for posterior perforations.
While the view is better than with a
transcanal approach, it is not suited to
anterior perforations.
Surgical Steps
Infiltrate the site of the endaural skin
incision as well as the ear canal in 4
quadrants with local anaesthetic
(lidocaine 1% and adrenaline diluted to
2
1:200 000), using a nasal speculum to
expose the ear canal
A skin incision is made in the bony
external canal with a #15 blade from
the 12 o’clock position, spiralling
upwards between the cartilages of the
helix of the pinna and tragus (Figure
1). The incision is 1,5cm in length and
extends down to the bone
Figure 2: Posterior canal incision that
meets endaural incision
Figure 1: Endaural incision at 12
o’clock in right ear canal
Haemostasis is achieved using bipolar
coagulation
Using a #11 blade, a skin incision is
made in the posterior aspect of the
bony external canal parallel to the
annulus, starting at 8 o’clock (for right
ear) and ascending in a spiral fashion
to meet the endaural incision at 12
o’clock (Figure 2)
A Key raspatory is used to reflect the
canal skin and soft tissue laterally and
away from the edges of the
tympanomeatal flap (Figure 3)
An incision is made anteriorly in the
bony canal skin, parallel to the annulus
and remaining medial to the cartilage
of the ear canal. It starts at 2 o’clock
and meets the endaural skin incision at
12 o’clock (Figure 4)
Figure 3: Reflecting canal skin and soft
tissue laterally
Figure 4: Anterior incision starting at
2 o’clock
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Two endaural retractors are next placed
in the ear canal to improve exposure
(Figure 5)
The edges of the perforation are
freshened using a sickle knife before
elevating the tympanomeatal flap
The middle ear is entered by elevating
the tympanomeatal flap at the level of
the posterior tympanic spine (Figure 7)
Figure 7: Elevating the tympanomeatal
flap
Figure 5: Placement of retractors
A tympanomeatal flap is elevated using
a Fisch microraspatory and adrenaline
gauze
If a prominent tympanosquamous
suture prevents good exposure, then it
needs to be drilled away using a 2,7mm
diamond drill (Figure 6). To avoid
bone dust from entering the ear, place
gelfoam soaked in Ringer’s lactate into
the perforation. Never leave gauze or
cotton in the surgical field that can be
caught up in the drill bit.
The annulus starts at this level and can
be easily dissected free of its sulcus
using the microraspatory as a shovel
Identify and preserve the chorda
tympani immediately beneath the
tympanic spine at this level
In order to assess ossicular chain
mobility, use the small end of a curette
to remove the posterior tympanic spine
and bone of the posterior canal wall
until the incus, incudostapedial joint,
lateral process of the malleus and
round window are visible (Figure 8)
Tympanomeatal
flap
Malleoincudal
joint
Long process
of incus
Stapedius tendon
Chorda tympani
Figure 8: Middle ear structures after
curetting posterior tympanic spine
Figure 6: Tympanosquamous suture
drilled away
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Use a 1,5mm, 45° hook to palpate the
malleus and incus. If the ossicular
chain is intact, then proceed to graft the
perforation
Tragal perichondrium is generally
harvested via the endaural incision and
placed as an underlay graft beneath the
edges of the perforation. Posteriorly
and superiorly it is laid onto the bony
canal lateral to the posterior tympanic
sulcus. Temporalis fascia may also be
harvested via the endaural incision or
through a separate postauricular
incision and used as a graft
The tympanomeatal flap is returned to
its original position and gelfoam
pledgets are placed over the graft to
secure it over the posterior tympanic
sulcus
The endaural skin incision is closed
with 3/0 Nylon sutures
Retroauricular Approach
A retroauricular incision is made close to
the hairline with soft tissue and pinna
reflected anteriorly. It is favoured for
anterior perforations. It allows one to do a
circumferential canalplasty in cases where
there is a significant anterior bony
overhang.
Surgical Steps
Using local anaesthetic (lidocaine 1%
and adrenaline diluted to 1:200 000),
infiltrate the post-auricular sulcus.
Then advance the needle and infiltrate
the tissues anteroinferiorly and
anterosuperiorly
Using a Lempert’s speculum to
visualise
the
bony-cartilaginous
junction of the ear canal, inject the 4
quadrants of the skin of the ear canal
(Figure 9)
A postauricular incision is made about
2cm behind the retroauricular sulcus
extending from the upper border of the
pinna to the level of the mastoid tip.
Light crosshatchings are made with a
scalpel before incising the skin, to
facilitate aligning the skin when
closing the wound
Figure 9: Points of injecting ear canal
Use a large rake retractor to reflect the
pinna anteriorly with the left hand
while developing a tissue plane
anteriorly toward the external ear
canal, using a scalpel with a #10 blade
The scrub nurse or assistant uses a
large suction tube to clear excess blood
so that no time is lost trying to achieve
haemostasis while elevating the skin
As the flap is developed the posterior
auricular muscle is encountered. This is
transected in order to get into the
correct surgical plane. Superiorly, the
temporalis fascia comes into view
(Figure 10)
A retroauricular periosteal flap is now
developed which is anteriorly-based.
The vertical incision is made
approximately 1,5cm from the ear
canal (Figure 10). Using a #10 blade,
the superior incision is extended
anteriorly along the linea temporalis up
to 12 0’ clock relative to the bony ear
canal. The inferior incision is extended
to the inferior border of the ear canal
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ear canal is then visible through the
incision (Figure 12)
Temporalis
fascia
Periosteal
flap
Figure 10: Temporalis fascia and
retroauricular periosteal flap
The periosteal flap is elevated from the
bone with a mastoid raspatory until
both the Spine of Henlé and the bony
external canal up to the 12 o’clock
position, are exposed
The next step is to raise a meatal skin
flap. The authors favour a spiral flap
technique, which should be practiced in
the temporal bone laboratory and will next
be described (Figure 11). (Spiral flap
video)
Figure 11: Incisions for spiral flap
technique
Elevate the periosteal flap up to about
2mm deep to the lateral edge of the
bony external ear canal
Using a #11 blade, enter the ear canal
via a transverse incision in the
posterior ear canal skin at about 8
o’clock (right ear). The lumen of the
Figure 12: Incising posterior ear canal
Cut with the scalpel in a cephalad
direction and extend the incision
superiorly up to 12 o’clock. It is
important that the blade remains on the
bone. The first incision now extends
from A - B (Figures 11, 13)
Figure 13: Posterior incision extended
as spiral incision to anterior canal wall
An incision is now made from C - B in
the skin of the anterior wall of the ear
canal starting at 2 o’clock and extended
superiorly to meet the previous incision
at 12 o’clock (Figure 13, 14). This
incision
runs
lateral
to
the
tympanosquamous suture line and also
has to remain on bone and medial to
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tragal cartilage; if the incision is placed
too laterally then the tragal cartilage
will be injured
Figure 14: Incising anterior ear canal
Use a Key raspatory to elevate the
lateral canal skin from the underlying
bone (Figure 15, 16)
Attach a sharp towel clip to the
periosteal flap at the level of the canal
to reflect the pinna and soft tissue
forward
Two self-retaining retractors are placed
superiorly and inferiorly and used to
reflect the soft tissue and improve
exposure. In children, one retractor is
sufficient
The meatal skin is now further incised
anteroinferiorly from D to C, starting
close to the tympanic membrane at
about 5 o’clock (Figure 16). The
incision spirals laterally and superiorly
along the anterior canal wall to meet
the earlier incision made in the anterior
canal at 2 o’clock (right ear)
A common mistake when doing this
flap for the first time is not incising the
skin fully onto the bone and this causes
the flap to tear when elevating it with
the microraspatory; it is therefore
important that the blade stays hard on
bone when making the canal incisions
The
meatal
skin
flap
is
circumferentially elevated from the
underlying bone with a Fisch
microraspatory (Figure 17)
Figure 15: Elevating skin from bone
Figure 17: Fisch microraspatory used to
elevate meatal skin off bone
Figure 16: Completing incision in
anterior canal wall
To keep this dissection blood-free and
to avoid injuring the skin flap,
adrenaline-soaked gauze is placed
between the Fisch microraspatory and
the meatal skin. Suction is never
directly applied to the meatal skin flap;
rather the excess blood is suctioned
through the adrenaline-soaked gauze.
The blade of the Fisch microraspatory
7
stays vertical to the bone and the
shoulder of the instrument is used to
push against the adrenaline gauze
which then atraumatically elevates the
very fragile meatal skin (Figures 17,
18)
Figure 19: Incising posterior limb of
meatal skin flap 2mm lateral to
annulus
Figure 18: Elevating meatal skin
The meatal skin is elevated until the
posterosuperior margin of the tympanic
membrane and the anteroinferior
overhang of bone are exposed
At the tympanosquamous suture line
(located posterosuperiorly) the skin
flap is very tightly bound to the
underlying bone and may be dissected
free using the following technique:
Using the raspatory like a shovel, free
the skin flap posterior to the suture.
Then elevate the flap anterior to the
suture. After freeing the flap
posteriorly and then anteriorly, there
may still be a remaining bridge of soft
tissue connections to the suture which
is cut with Bellucci scissors
Using a #11 blade incise the posterior
limb of the meatal skin flap 2mm
lateral and parallel to the annulus
(Figures 19, 20)
Figure 20: Incise posterior limb of
meatal skin flap 2mm lateral to and
parallel to the annulus
Bellucci scissors are then used to
continue incising the meatal skin flap
2mm lateral to and parallel to the
annulus until the anterior part of the
flap is reached (Figures 20, 21)
Transect the remaining meatal skin to
6 o’clock, 2mm lateral to the annulus,
using an Iowa raspatory or a round
knife (Figure 21)
8
the soft tissue is elevated out of the
bony external canal, leaving it pedicled
inferiorly (Figures 23, 24)
Figure
21:
Extending
incision
anteriorly, remaining 2mm lateral to
and parallel to annulus
Figure 23: Flap pedicled inferiorly and
elevated from canal wall
Figure 22: Transect remaining meatal
skin to 6 o’clock, 2mm lateral to the
annulus
Using the larger (Iowa) raspatory the
meatal
skin
lateral
to
this
circumferential incision is dissected
free from the bony canal. Using a
bigger instrument avoid injuring the
inferiorly based pedicle (Figure 22)
Elevate the lateral aspect of the anterior
meatal skin flap with a Key raspatory
and using two hands, advance the
raspatory over the lateral rim of the
tympanic bone (Figure 23)
Once the lateral edge of the tympanic
bone is reached, keep the tip of the
instrument in contact with the bone and
underlying tissue but swing the handle
of the Key raspatory anteriorly so that
Figure 24: Soft tissue is elevated out of
the bony external canal
The spiral of elevated meatal skin is
kept out of the surgical field by using
the aluminium strip or ribbon of the
surgeon’s mask which has been
sterilised. First, the ribbon is passed
through the teeth of the self-retaining
retractor (Figure 25). Then artery
forceps are used to place it against or
pass it around the meatal skin flap
(Figure 26). The ribbon is then folded
back over the top of the retractor
(Figure 27)
9
With perforations only involving the
posterior quadrant where the entire margin
of the perforation is visible, performing a
canalplasty is unnecessary. However there
is often a bony overhang anteriorly and/or
posteriorly which restricts the surgeon’s
view. If the perforation extends to involve
the anterior quadrant then it is necessary to
do a canalplasty.
Figure 25: Ribbon passed through
teeth of self-retaining retractor
Figure 26: Ribbon passed around
meatal spiral flap
Figure 27: Ribbon secured to selfretaining retractor
Canalplasty (Canalplasty video)
Surgical steps
Standard retroauricular approach
Elevate meatal spiral flap
If there is a tympanic membrane
perforation, gelfoam soaked in
Ringer’s Lactate is placed over the
perforation to avoid bone dust entering
the middle ear
Starting with a 2,7mm rough diamond
burr, enlarge the ear canal by drilling
away any bony overhang
Commence drilling posteriorly, then
move inferiorly and finally drill the
anterior canal wall
The technique of skeletonisation is
important. With the correct technique
the bluish colour of the temporomandibular joint (TMJ) will show
through the irrigation; this should alert
one to stop drilling before the joint is
entered
It is important to check that burr sizes
are correct by first placing a new burr
in the canal before using it
Always drill under direct vision and
never behind overhanging edges of
bone. In this way one avoids opening
mastoid air cells or injuring the facial
nerve posteriorly and TMJ anteriorly
Use the Fisch microraspatory (with
adrenaline gauze) to elevate the meatal
skin before drilling away bony
overhangs (Figure 28)
It is imperative to have an adequate view
of the annulus as well as all the edges of
the perforation to do an adequate
myringoplasty or tympanoplasty operation.
10
Figure 28: Microraspatory used to
elevate meatal skin using adrenaline
soaked gauze
When drilling close to meatal skin, a
diamond burr is used so that the meatal
skin is not injured by the burr
The microraspatory is held perpendicularly to the bone at the level of the
annulus; the tip of the microraspatory
is not visible because of the anterior
bony overhang. Using this technique,
one can determine how much bone
needs to be removed before reaching
the annulus (Figure 29)
Figure 30: Bony overhang drilled
away using a small diamond burr
The inferior trough technique allows
the surgeon to gauge the depth of the
annulus: using a diamond burr, drill at
6 o’clock from medially to laterally to
create a groove. Continue to drill until
the white colour of the annulus
becomes visible at the level of the
sulcus (Figure 31)
Figure 31: Inferior trough technique
Figure 29: Tip of microraspatory used
to determine how much bone needs to
be removed lateral to annulus
This bony overhang is then drilled
away, using a small diamond burr
(Figure 30)
Now continue to expand the drilling
from the groove outwards and
circumferentially
Once the canalplasty has been
completed the entire annulus should
be visible with one view of the
microscope and no bony overhang
should remain (Figure 32)
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Figure 32: Completed canalplasty with
entire annulus visible and no bony
overhang
Figure 34: Ivalon®
Following grafting of the tympanic
membrane perforation (see later) the
meatal skin flap is replaced (Figure 33)
Figure 35: Ivalon® used to secure the
meatal skin
Figure 33: Meatal skin flap being
replaced
The meatal skin is secured with
gelfoam pledgets placed medially over
the graft. Two pieces are cut from an
Ivalon® ear wick and inserted laterally
into the ear canal over the meatal flap
(Figures 34, 35). Ivalon® has a smooth
surface which is placed on the outside
(facing the meatal skin) to allow for
atraumatic
removal
one
week
postoperatively
The postauricular periosteal flap is
replaced and secured with 3/0 Vicryl
sutures (Figure 36)
Figure 36: Securing the retroauricular
periosteal flap
Ensure that the skin of the meatal flap
is applied to the bony canal and
extends lateral to the Ivalon® ear wick
(Figure 37)
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Figure 37: Checking correct placement
of meatal skin
Antrotomy
An antrotomy is performed in conjunction
with a myringo- or tympanoplasty when
eustachian tube function is questionable or
in the presence of polypoidal middle ear
mucosa obstructing the epitympanum
(Figure 38).
Figure 38: Antrotomy defect
The detailed surgical steps for antrotomy
are presented in the chapter on Mastoidectomy and epitympanectomy
Epitympanic patency is determined by
means of the water test: Ringer’s solution
is irrigated into the antrum to test whether
there is free communication between the
antrum and the middle ear (Figure 39)
Figure 39: Antrum irrigated with
Ringer’s solution
If the test is positive, there is no need to
further explore the epitympanum
If the test is negative, then one needs to
explore the epitympanum
If abnormal mucosa is removed from
the epitympanum but the ossicles are
left intact, this is defined as an
epitympanotomy.
If malleus head and incus need to be
removed to re-establish patency, this is
referred to as an epitympanectomy
Following the procedure, a groove is
drilled posteriorly into the mastoid
bone to accommodate a transmastoid
drain
A separate stab incision is made
posterior to the retroauricular skin
incision and the drain is fixed to the
skin using a silk suture
The patient may perform Valsalva
manoeuvres from the 2nd day following
surgery
The mastoid drain is usually removed
after 2-4 days
Grafting tympanic membrane
perforations
Choice of graft material
Temporalis fascia is widely used to
reconstruct the tympanic membrane. It
13
is easily accessible and long-term
results are comparable to that of
cartilage tympanoplasty. An advantage
of temporalis fascia is that recurrent or
residual cholesteatoma can easily be
identified behind the reconstructed
tympanic membrane
Tragal perichondrium
Cartilage is preferred in certain
instances due to its resilience: it may
be used to reinforce an atrophic
tympanic membrane; it is used in
addition to fascia in a closed
mastoidoepitympanectomy to reconstruct the posterior canal wall; and
certain middle ear prostheses require
reinforcement of the overlying
tympanic membrane to prevent
extrusion through tympanic membrane
Figure 40: Exposing temporalis fascia
Harvesting temporalis fascia
Temporalis fascia consists of a superficial
and a deep layer. The deep layer is used for
grafting because it is thicker and more
resilient. The fascia is easily harvested
from the retroauricular region if a
retroauricular approach has been used via
the same incision. It is preferable to
harvest the fascia at the end of the
procedure once the surgeon knows how
much fascia is required.
An assistant exposes the fascia by
superiorly retracting skin and soft
tissue with a rake retractor (Figure 40)
The superficial layer of fascia is
divided and separated from the deep
layer with tympanoplasty scissors
A transverse incision is made in the
deep layer of fascia parallel to linea
temporalis with a #11 blade. The
undersurface of the fascia is undermined through this incision and
separated from the temporalis muscle
with scissors (Figure 41)
Figure 41: Undermining deeper layer
of temporalis fascia
Harvest the appropriate amount of
fascia with scissors taking only as
much as is needed so that should the
patient require revision surgery,
additional fascia can be harvested
The fascial graft is compressed
between two gauze swabs, but not
dried
The graft is then placed on a silicone
block. The scrub nurse holds one
corner of the graft, while the surgeon
holds the other corner with anatomical
forceps, and using a #10 blade, the
graft is scraped clean of muscle fibres
(Figure 42)
Uneven edges are trimmed with a #10
blade
An incision is made in the flap with a
knife to accommodate the tensor
tympani tendon at the anticipated
location of the malleus handle (Figure
43)
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Harvesting tragal cartilage and tragal
perichondrium
Figure 42: Scraping muscle off fascia
Figure 43: Incision to accommodate
tensor tympani tendon
When doing revision surgery it is
possible to extend the postauricular
incision superiorly in order to find
additional temporalis fascia (Figure
44)
Figure 44: Extended postauricular
incision for additional temporalis
fascia
Tragal cartilage is easily harvested by
exposing the upper end of the tragal
cartilage through an endaural approach
Hold the tragal cartilage with surgical
forceps while dissecting the soft tissue
off the cartilage with tympanoplasty
scissors
After exposing the amount of cartilage
required for reconstruction, resect
cartilage with overlying perichondrium
with tympanoplasty scissors
Using the operating microscope strip
the tragal perichondrium from the
cartilage with a microraspatory. The
perichondrium may also be left
attached to the tragal cartilage when
reconstructing the posterosuperior
canal wall
To thin cartilage, hold it with Hudson
Brown forceps and section the cartilage
with a new #10 blade
Grafting Techniques
The authors use the terms “underlay” and
“overlay” to refer to position of the graft
relative to the bony (annular) sulcus. (In
other texts it may refer to the position of
the graft in relation to the tympanic
membrane)
With underlay technique the graft is
placed medial to the remnant of the
tympanic membrane and anterior
tympanic sulcus
With overlay technique the graft is
placed lateral to the tympanic sulcus
Underlay technique is most often used for
perforations involving the anterior
quadrant. The graft is always placed
medial to the malleus handle. Larger
perforations often require a combination of
anterior underlay and posterior/inferior
overlay grafting technique.
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Grafting limited perforations of the
posterior quadrant (Figure 45)
Figure 45
These surgical steps are discussed in detail
under endaural approach
Grafting perforations that reach the
anterior quadrant (Figure 46)
Figure 47: Dividing the tympanomeatal flap posteriorly
Scrape the undersurface of the
tympanic membrane remnant with a
1,5mm, 45° hook
Anteriorly, the graft is underlaid under
the edge of the tympanic remnant
If the perforation extends inferiorly or
posteriorly then the graft is underlaid
anteriorly but overlaid posteriorly in
the inferior or posterior quadrants
The meatal skin flap is replaced
(Figure 48)
The fascia and meatal skin flap are
secured with Gelfoam
Figure 46
Retroauricular approach is used
Canalplasty is done
The annulus is not elevated between 2
and 4 o’clock (right side) as this will
cause blunting of the anterior
tympanomeatal angle and lateralisation
of the tympanic membrane resulting in
reduction of vibratory properties of the
tympanic membrane
If the perforation involves the
anteroinferior quadrant then the
tympanomeatal flap
is
divided
posteriorly after it has been elevated
(Figure 47)
Figure 48: Meatal skin flap is being
replaced
16
Grafting perforations that reach the
anterosuperior quadrant (Figure 49)
to as close as possible to the
“buttonhole”
Use a microsuction tube to suck and
pull the “tongue” of temporalis fascia
through the “buttonhole” and then use
a 1,5mm hook to advance the graft into
position (Figure 51)
Figure 49
Retroauricular approach is used
Canalplasty is done
Elevate and divide the tympanomeatal
flap posteriorly (Figure 47)
Scrape the undersurface of the
tympanic membrane remnant with a
1,5mm, 45° hook
Fixing the graft anteriorly requires
special anterior support
Detach the tympanic annulus between
1 and 2 o’clock (right ear) using a
microraspatory to create a “buttonhole”
anteriorly between annular ligament
and bone (Figure 50)
Figure 51: Use a microsuction tube to
suck and pull “tongue” of temporalis
fascia through “buttonhole”
Grafting subtotal perforations (Figure 52)
Figure 52
Figure 50: Detach tympanic annulus
between 1 and 2 o’clock to create
“buttonhole” anteriorly
The fascial graft is placed medial to the
malleus
A small “tongue” of the graft is
manoeuvred with a 1,5mm 45° hook,
Retroauricular approach is used
Canalplasty is done
Elevate and divide the tympanomeatal
flap posteriorly (Figure 36)
Subtotal perforations may only have a
limited remnant of the tympanic
membrane anteriorly
Scrape the undersurface of the
tympanic membrane remnant and
adjacent bone with a 1,5mm, 45° hook
17
The graft is underlaid both under the
tympanic membrane and malleus
handle
The graft is supported anteriorly by
placing small pieces of Gelfoam
soaked in Ringer’s lactate beneath the
graft (Figure 53)
Figure 55: Gelfoam placed laterally to
secure graft
Management of severely retracted
malleus with chronic otitis media with
Figure 53: Graft supported anteriorly
by Gelfoam soaked in Ringer’s lactate
Superiorly both limbs of the fascia
overlap just above the neck of the
malleus (Figure 43)
Posteriorly and inferiorly, the graft is
positioned as an overlay graft
Figure 54: Fascia overlaps just above
neck of malleus
Gelfoam is then placed laterally over
the graft to secure it in place over the
tympanic sulcus (Figure 55)
Occasionally patients with longstanding
chronic otitis media do not develop erosion
of the incus, but the malleus handle
becomes medialised. In severe cases the
umbo of the malleus touches or even
attaches to the promontory. This presents a
challenge insofar as that the tympanic
membrane perforation needs to be
reconstructed and at the same time the
hearing needs to be improved. If fascia is
placed as an underlay graft it will result in
Grade 4 atelectasis and may subsequently
reperforate. Lateralisation of the malleus
is easily achieved once the incus has been
removed. The following is an effective
technique to manage a severely retracted
malleus:
The malleus head and anterior mallear
ligament are removed leaving the
tensor tympani tendon intact
An incus interposition is then done
The perforation is grafted with fascia
or cartilage by underlay technique
Because the malleus has been
lateralised it facilitates placement of
the graft in the proper position
18
Reconstruction with closed mastoidoepitympanectomy
Reconstruction with open mastoidoepitympanectomy
See the mastoidoepitympanectomy chapter
for a description of reconstruction at the
time of primary surgery
The defect is often located superiorly
in the epitympanum
Cartilage is used to reconstruct the
defect in the epitympanum
Temporalis fascia is placed beneath the
handle of the malleus so that the two
tongues of the fascia overlap each other
in the epitympanum (Figure 56)
See the Mastoidectomy and epitympanectomy chapter for a description of reconstruction at the time of primary surgery
A circumferential tympanic groove is
drilled with a small diamond burr to
form a new tympanic sulcus
The graft is placed as with repair of a
subtotal perforation
If a 2nd stage ossiculoplasty is planned
then it becomes necessary to place
silastic sheeting in the middle ear and
protympanum
Ossiculoplasty
Ossiculoplasty is defined as reconstruction
of the hearing mechanism by establishing a
connection
between
the
tympanic
membrane and the oval window. It is
covered in detail in the chapter
“Ossiculoplasty”
Figure 56: Temporalis fascia placed
beneath handle of malleus so that two
tongues of fascia overlap
An alternative technique is to position
the graft such that the two tongues are
positioned around the malleus and
overlap each other in the middle ear
beneath the malleus handle (Figure 57)
References
1. Fisch U, May J, Linder T.
Tympanoplasty, Mastoidectomy, and
Stapes Surgery. New York: Thieme;
2008.
2. Lerut B, Pfammatter A, Moons J,
Linder T. Functional Correlations of
Tympanic Membrane Perforation Size.
Otol Neurotol. 2012; 33:379-86.
3. Hol KS, Nguyen DQ, Schlegel Wagner
C, Pabst G, Linder TE. Tympanoplasty
in chronic otitis media with an intact,
but severely retracted malleus: A
treatment challenge. Otol Neurotol.
2010;31:1412-6.
Figure 57: Two tongues overlap in
middle ear beneath malleus handle
19
Acknowledgments
Editor
This surgical guide is based on the text by
Professor Ugo Fisch (Tympanoplasty,
Mastoidectomy, and Stapes Surgery) and
the personal experience of Professor
Linder, as well as course material for the
temporal and advanced temporal bone
courses conducted annually by Professors
Fisch and Linder at the Department of
Anatomy,
University
of
Zurich,
Switzerland.
Johan Fagan MBChB, FCORL, MMed
Professor and Chairman
Division of Otolaryngology
University of Cape Town
Cape Town, South Africa
[email protected]
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THE OPEN ACCESS ATLAS OF
OTOLARYNGOLOGY, HEAD &
NECK OPERATIVE SURGERY
www.entdev.uct.ac.za
The Open Access Atlas of Otolaryngology, Head &
Neck Operative Surgery by Johan Fagan (Editor)
[email protected] is licensed under a Creative
Commons Attribution - Non-Commercial 3.0 Unported
License
Author
Tashneem Harris MBChB, FCORL,
MMED (Otol), Fisch Instrument
Microsurgical Fellow
ENT Specialist
Division of Otolaryngology
University of Cape Town
Cape Town, South Africa
[email protected]
Senior Author
Thomas Linder, M.D.
Professor, Chairman and Head of
Department of Otorhinolaryngology,
Head, Neck and Facial Plastic Surgery
Lucerne Canton Hospital, Switzerland
[email protected]
20